^ 

I 

TRANSMITTAL of OMAHA LEAD SITE 

PAINT STABILIZATION FILE FOLDER 

SAID: 20670 Date: 12/26/2008 A 

\ 

Address: 2955 HARRIS 

Stabilization Contractor: Prudent Technologies Year: 2008 

PAINT STABILIZATION 

PROPERTY FILE FOLDER DOCUMENTS 

ef Video of property (DVD) 

0 Executive Sununary 

0 Signed Access Agreement for subject property 

1^ Painting Agreement 

D Settlement documents (i.e., for damage or to replace plants, etc.) 

D Photographs 

^ Satisfactory restoration signed by Property Owner 

D Property close-out check list signed by EPA 

0 Property information from Douglas County Assessor's Office 

D 

D • 

D 

Sot ^^$*n o»Joz/oT 

Signatiue Date 

40307987 

•ii 

Superfund 
PROPERTY SUMMARY 

Date: 12/29/08 LBP STABILIZATION EPA CONTRAT EP-R7-08-07 Month of: December 

Property Address; 2955 HARRIS SAID; 20670 

A. EXECUTIVE SUMMARY 

A.1 Issues Encountered; 

A.2 Issues Resolved: 

A.3 Unique Findings: NONE. 

A.4 Other Relevant Information: 

Access Date; 10/30/08 

Work Began: 11/11/08 

Closeout Date; 11/13/08 

Enclosures: 

1. Pre-Video 

2. Post-Video 

3. Property Status Form 

4. Signed Access Agreement 

5. Pre-Renovation Form 

6. Paint Match Form 

7. Tracking Form 

8. Douglas County Assessor Property Information Page 

9. EPA Property Closeout form 

10. Property Completion Agreement 

TECHNOLOCIES, INC. 
ENVIRONMENTAL & 

CONSTRUCTION 

SERVICES 

Property Status Form 

Address: p9 3 J) MOLA.'VJU ^ ' Date: /7?/^f/c ^ 

Phone: tilTPlant & Permanent Landscaping To Remain In Place 

Iteai# 

Desdription and Location 

On Map 

Pre-Existing Condition of Stroctures 

Does ^our Basement have a histoiy of leaking? Yes — No 

Iteni# Descr ption & Location 

OnMiq) 54»' ' {7i^w\af^ i c f^tc h FffA/DC. 

fV^I 'p£:r^y. \ 

U&TZS^ ^ 

$\c/)h f <^e^yHcL<s£ C6oy^^Z) 

Prop Brty Owner Pradent Employee 

Signhtwre; A ZH^ruiAf/i Signature: J'&^ t k A . .•• - «* a T 4242 Madlcal Drtva, 8uNt4t80 4«M U 91 *fttNMrt. Strfte SOS 
JC^u^nC^ 

Piudent Technologies, Inc. (Prudent) is under conttact (Contract # EP-R7-08-07) with tiie U. S. 

Environmental Protection . \gency (EPA) to stabilize Lead Based Paint (LBP) at a number ofproperties 

located in Omaha, Nebraslpa, including tiie property located at c3^St S /VCCA,'UJ-\ 5U . 

The EPA requests your peimission to allow Prudent to perform LBP Stabilization at this propeity. By 

signing this form, tiie propprty owner grants permission to Prudent to perform activities related to LBP 

Stabilization including g paint and painting of the referenced property. Furtiier, the owner/tenant 

verifies that they have rec^ved tiie LBP pamphlet "Renovate Right." 

If you have any questions kbout tiie LBP stabilization planned for your property, please contact Prudenf s 

Adminisrtnjtive Clerk for t le Lead Based Paint Stabilization, Mrs. Deborah Akerele-Johnson. 

at (402) 504-1004. Genen il questions about the Omaha Lead Site cleanup can be directed to the EPA 

Public Information Center^ at (402) 731-3045 (Soutii Omaha ofBce) or (402) 991-9583 (North Omaha 

office). 

Property AccciiOnBMedBv: A K^QwC^rte^^ JenrvuhO 

^eas e Prim Name) 

Propoty Owner Signdura: X ._ .y^k^iyJh^ )ij^^AiA^ (e ^TA^ 

(Signatu^ ^7 / ) 

PROPERTY INFORMATION 

(To be completed by raident aad/or property oirner- pleaie print) 

RESIDBrrNAME; Cooc-lAe\i FfAAAd/^ Renter 

RESIDENT ADDRESS;. '7^F5' llarrU 5^. 

W RENTAL. PROPERTY OWNED 3Y: 

Carrie OWNER'S MAIUNO ADDRESS; 

OWNER'S TELEPHONE NUMBEF .HOME: jtoiiiHlf£2^W0RK ; >^/^l ^^-X/^ 7 

NUMBER OF OCCUPANTS UNDE R 7 YEARS OLD . NUMBER OF OCCUPANTS 7 YEARS OLD AND OLDER^ ; 

NUMBER OFOHILDREN UNDER r YEARS OLD VWO PLAY IN THE YARD FOR 6 HOURS OR MORE PER WEEK: 

COMMENTS OR SPECIAL IN8TR JCTIONSy.: (I.& DOGS, ENTRY QATES. ETC.) 

7 ^ & 

AU1H0IUTY FOR ENVmONMENI AL RESPONSE ACnONS; Theactivitieetobeinipleinentedby BPA under tUi agreement aiepiimant to Section 104 

Of CERCLA. 42 U.S.C 9604. EPA'a I igtit of aoceu to the property is provided fbr in Section 104(e) of CERCLA, 42 U.S. C 960S(eX wiiich providei entry 

fbr "detenniningthe needfor retponsc, or choosing ortaking any response action under this title, or ofierwise enlbtcing ftc provisions of the title." 

980 Wanl Paitany. 8i««409 2505 N. 24" Straet, Suite 308 4242 Medical Drive. Suite 4260 

:anM*CHy. MO 64114 Omaha. Nebraaka 68110 San Antonio. TX 78229 •hAMf ffilAI MAJlTin 
uurren • ^ 1 i oampie rie-ttpnovaiion rorm 

Effective until April 2010. 

Confirmation of Receipt of Lead Par iphlet 

Q I have received a copy of the pampt|ilet , RefTovate Right Important Lead Hazanj 

Infonnation for Families, Child Care Rnowctefs and Schools informing me of 

the potential risl< of the lead hazanj wposure from renovation activity to be 

performed in my dwelling unit. I received this pamphlet before the work began. 

A L/^i^r "hve JA . \ >gvrvn*^i>n 7c)M'fJ(^ 

Printed/ame of recipient Jn^' 

" 

Date "^ "^ 

1 " ' a^p^^fiAi-^f^ 

Signature of recipient' / ' 

Self-Certification Option (for tenant-occupied dweiiings only) — 

If the lead pamphlet was delivsnad but a tenant signature was not obtainable, 

you may check the appropriate box bejow. 

Q Refusal to sign — I certify that I ha/e made a good faith effort to deliver the 

pamphlet, Renovate R^ t lmportar\t Leacy Hazard Information for Families, 

Child Cam Pmviders and Schools, the rental dwelling unit listed below at the 

date and time indicated and that ti occupant refused to sign the confirmation 

of receipt, i further certify that I have left a copy of the pamphlet at the unit with 

the occupant. 

Q Unavailable for signature — I certfy that I have made a good faith effort to 

deliver the pamphlet, Renovate Hi Rigl i t '; Important Lead Hazard Infomiation for 

Families, Chiki Care provkiers and Schools, to the rental dwelling unit listed 

below and that the occupant was upavailable to sign the confirmation of receipt. 

I further certify that I have left a cop^ of the pamphlet at the unit by sliding it 

under the dogp^ 

pieoiy?-^ /T^Mod'' 

Printed name of person certifying 

Attempted delivery 

date and time 

lead pamphlet delivery 

Signature of person certilying lead p phlet delivery 

9^ ?Sf 1\ 

O/IActhciV-' A/r 

Unit Address 

Note Regarding Mailing Option —•/s an aitematlve to delivery in person, you 

may mail the lead pamphlet to the owper and/or tenant. Pamphlet must be mailed 

at least 7 days before renovation (Doqument with a certificate of mailing from the 

post office). 
f^i'nt matchi ^w ^ i_ 

?p 

Anna Z-^'^'"''^/ ^, 

- ^ Ce.U^', Forck iUar^ forok ZlXLiFa^t:.o "'^^'"'^ 

lUh i i € 

I O ^a-'//oA i i 

(parage ^iJii^i. i^dAtAT 

Area: ^^-^^r^s ^ 

Color: ^'iyUy^t7y Se'/'y^ 

Explanation: 3F7 y^/7oiA^ 

/l^jf.' OLU^er e^^'ii^./io/i/y /'f^>^ ^^^^e'/) 

Area: 

Color; 

Explanation: 


' ^ ^fSi /^ ^ ^ S/dma I 

Area: 


Color: 

Explanation: 


Area: 


Color: 

Explanation: 

Page i 
c Aca Siis iMPOi^HyiorfTKACKKQ SHEET 

52?^

fllMrfWItWNIt 

 7 ^ PftcpterV 

[y& o /// J e y

f 6 9 /i^^'^J^r^ y t y;,—• 

 ^eAAuiVK 

 S)/ 

dDBrOonxlNo: Honw. 

0Airl-^/Zli?Z2_ 

V*fK 

M. 

/yttAdJ^A^ 
Douglas County Account ljntorM||tio )ratt|i( n rage i Ui J 

Douglas County, Nebraska Property Record - R0917710000 

Print Report 

NEW Feature - Parcel Dimensions available @ scale 0-60 ft west of SOth St - ViCW On iVlap information is valid as of 20(18-9-4 Treasurer's Tax Report 

New Feature -*->- * Auto Sales Search 

Owner 

FLOYD COURTNEY 

2955 HARRIS ST 

OMAHA NE 68105-0000 

Property Informatio n 

Key Number: 1^71 0000 09 

Account Type: Residential 

Parcel Number: 0^17710000 

Parcel Address. 2!)55 HARRIS ST 

OMAHA NE 68105-0000 

Legal Description: DEAN PLACE LOT 11 BLOCK 0 E 40 FT 40 X 100 

Value Informatio n 

Land Improvement Total 

2008 i $5,1200,00 $94,300,00 $99,500.00 

2007 j $5,200.00 $94,300.00 $99,500.00 

2006 __ I $5,200.00 $74,800,00 $80,000.00 

2005 _ I $5,1200.00 $74,800.00 $80,000.00 

2004 j $5J200.00 $74,800.00 $80,000.00 

2003 $5J200,00 $74,800.00 $80,000.00 

Sales Informatio n 

Sales Date: 2005-03-25 

Deed Type: Vi/D Book: 2005 Page: 037778 

Price: 585,000.00 

Grantor: E renda S Walenz 

Grantee Courtney Floyd 

Valld/lnvalld: \jralid 

Exclusion Reason 

Sales Date: 1993-01-28 

Deed Type: 1) Book: 1947 Page: 084 

Price: ; 134,000.00 

Grantor: 

http ://douglasne.mapping-online .com/DouglasCoNe/static/accountinfo .j sp?accountno=R09... 10/1 /200 8 
/v/ugjuo v^uuiiLj' rrv^cuuill. . lUUlIililLlUll Fage 2 ot 3 

Grantee: 

Valid/Invalid: 

Exclusion Reason: 

Viilid 

Acres : SF 

0.09 400C 0

Improvemen t Informatio n 

Building 1 

Unite 

 1.0 

Depth Width 

100.0 40.0 

1 1/2 Story Fin 

Vacant 

No 

Bsrr:rir Boz< 8 ft 

936 0 sc. 1 

Square Footage: P54.0 Percent Complete: 100.0% 

Perimeter 0 Quality: Average 

Unit Type: Condition: Average 

Built As: 1/2 Story Fin Condo Square Footage: 0.0 

HVAC: Oentral Air to Air Rooms: 6,0 

Exterior: Frame' Vinyl Units: 1.0 

interior: Crywall Baths: 2.0 

Roof Cover: Composition Shingle Bedrooms: 2.0 

Roof Type: Gable Stories: 1,5 

Floorcover: Allowance Foundation: Block 

Sprinitier Square Footage: 0.0 

YearBuilt Y(>ar 

Remi deled 

Percent 

Remodeled 

Adjusted Year 

Built Physical Age 

1915 0% 1915 941 

Detail Type Deta/7 Description Units 

Add On Fence Chain Link 1.0 

Appliance Allowance 1.0 

Basement Bsmnt Block 8 ft 936.0 

Fixture Base Fixtures 1,0 

http://douglasne.mapping-(>nline.com/DouglasCoNe/static/accountinfo.jsp?accountno=R09... 10/1/2008 
/wugiuj y^uuiiiy rvctUUlll JlUOIlj^lOn Page 3 of3 

Fixture Bath Full 2.0 

Garage i Detached 216.0 

Porch Slab Roof Ceil 208.0 

User MLS UPDATE 1.0 

http://douglasne.niapping-or.line.coni/DouglasCoNe/static/accountinfo.jsp?accountno=R09... 10/1/2008 
17"^.'^ ^ rr;' >'"^r«,\ ^'i-'~i^--i ^-^sr^vsgpi 

Prudent Property Ciose-Out Form (Lead-Based Paint Stabiiization) 

SMD:__?:^tZZ^—- — 

Property Address: '^f ^ /4^/VAi - •^'7 ' 

Owner's Name: 7!n{Jf^^AfA y <FkiA4'yf ^ 

Performance Standards/close-Out Criteria 

YES IN O 

1, Was the entire structure(s) painted with the exception of the stated, excluded aress? This w/ould 

include painting of other associated features including fascia, eaves, siding, all trim, porches, box 7 

beams, columns, rails, and exterior surfaces of garages. 

2, Was all scraping and other preparattion woric completed satisfactorily? "7 

3. Were all required areas of the structure(s) primed as needed and painted with two top coats? T 

4, Was the paint products utilized equivalent to a 30 year product/quality? z 

5, Are all of the areas where contaminated materials have been spilled 

thoroughiy vacuumed/ cleaned? y 

6. Did the contractor collect/vacuum all falling and scraped paint chips on the entire property, 

roadways, alleyways, public access areas and also remove any other generated debris? / 

7. Is the grass area that surrounds the structure(s) in reasonably good condition? 

8. Are all items such as polyethylene sheeting, ladders, paint brushes, cones, barrier tape etc. 

/ properly removed? 

9, Is there any evidence of property damage that was done by the contractor? Any property damage 

/ ' needs to be completed prior to the EPA Ciose-Out. 

10. Are there any property items that were temporatiiy re-located by the contractor y that need to be moved bacl<? 

11. Are there any (Icnown) lingering issues with the property owner{s) that have been left unresolved? y ^ 

Other Considerations?property Owner Discussions?Additiona! Work that is Required 

Prudent Representative Signature: cJ^*''^^''^; ^ 

y\(v7t ^y- ^ Date F7 ^

 ^//^/iic.^^^ ^ ^ 

Property Owner Signature: 

Date: